Wednesday, February 27, 2008

Docuslaves

(medical students, residents an PAs) While rounding this week I tried to determine how much time was spent writing in charts and doing all the documentation and charting that is required. It worked out to be about 5 minutes for a routine uncomplicated hospital follow up, 7-10 for a moderately complicated case and about 15minutes for a new consult. This was of course without the docuslaves, those who are there to learn medicine but instead are relegated to writing all the mumbojumbo in the charts that means nothing, that is only read by attorneys, insurance companies an JACHO. I woul so love if all that time was spent on the patients instead. I feel sorry for the rns, for them it is the opposite, the students do the real care while they are force to write all the stuff. It is the old story, if it isn't written in the chart it wasn't checked.

The real sad part is that the chart is what we are supposed to use to communicate with each other as we take care of the patient. There is now so much junk in it that it is hard to tell what is actually going on. Isn't better documentation great!

6 comments:

Jason Dittle said...

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Jason Dittle said...

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Supremacy Claus said...

Dr. T: Should anyone get second guessed on the quality of records in a lawsuit, see this:

http://www.ahrq.gov/downloads/pub/advances/vol2/pace.pdf

Click on Table 3. No correlation with harm.

As a patient in pain, I want relief. I don't care if the record is a squiggle. If the doc types away, documenting me, I throw the latop from the window, and remind, "I'm over here, Doc."

This record stuff is lawyers running their con to intimidate and to lawyerize medicine.

Throckmorton said...

SC:

I love it!

SeaSpray said...

I can appreciate your frustration Throckmorton!

I hope some good comes from all of this added detail. It is a shame that it cuts down on pt/dr/staff interactions because everyone is so bogged down trying to answer all the questions and just get through the system.

I was just speaking with one of my former co-workers today (ED nurse)and she does not like the new EMR system they are on because it takes so much time to get through everything and that it does just as you said - takes time away from the pts.

It has to be especially frustrating to people who have been in the business a long time and so know how simple it was...you cared for the pt, wrote up some notes/discharge instructions and now everyone has to enter something the length of War and Peace (ok-I'm being facetious)just to do their jobs. HIPPA, EMTALA, MDCR, JCACHO, etc., requirements abound.

Some of it is good and protects both pts and providers but it also seems like too much.

Since you are a surgeon you may appreciate this post by Dr Schwab over at Surgeonsblog. His "Man and Machine" post is about EMRs and the comments are interesting. If you do...make sure you click on his link at the bottom of the post called (Memos)which links to a previous post he did which is titled "When Surgery SUCS".

I love the memo/questionnaire he created for surgeons in response to the inane concern of JCAHO because they didn't have a record of any unnecessary surgeries. Hilarious! I may give it to my urologist whenever I see him again if I remember it.

Suicide Malpractice said...

I perused a printout of an inch thick EMR from another doctor, looking for current medications. I still haven't found them. I am gratified to know this pretty girl has both normal female genitalia, the penis is an anatomically correct penis, and both testes have descended.